The combined application of hand hygiene and non-sterile gloves by nurses in a tertiary hospital: a multi methods study.

BACKGROUND: The application of hand hygiene (HH) and the use of non-sterile gloves (NSG) in daily care is highly intertwined. We aimed (1) to assess the combined application of HH and NSG among nurses and (2) to explore determinants that influence their ability to combine both measures in their care. METHODS: In a multi-methods study, we combined direct observations of care episodes with semi-structured interviews with nurses in two affiliated university hospitals. Topics were based on Flottorp's checklist of determinants of practice. RESULTS: In total, we observed 205 care episodes and interviewed 10 nurses. Observations revealed that the combination of NSG and HH was correctly applied in 19% of care episodes in which a single procedure was executed, and in 2% of care episodes in which multiple procedures were performed. From the interviews, we found determinants that influenced compliance, covered mainly by three out of seven of Flottorp's checklist domains. Nurses indicated that their knowledge of protocols was limited to HH and protocols were hardly ever actively consulted; visual reminders within their workplace were used as sources of information. Nurses' behavior was primarily influenced by their ability to operationalize this information and their ability to integrate both infection prevention measures into their care. The intention to apply and combine HH and NSG use was influenced by their risk assessment of cross-contamination, by the urge to self-protect and gut feeling. The feasibility to execute HH and NSG protocols is influenced by the urgency and the complexity of the care episode. CONCLUSIONS: The combined correct application with HH and NSG measures by nurses is low. Nurses are instructed in a fragmented way while in the day to day care HH and NSG use are highly intertwined. Operationalization and simplification of infection prevention protocols, in which instructions on both infection prevention measures are fused, should be considered. Strategies to improve practice should consider the power of habit and nurses urge to self-protect.

De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before and after study.

BACKGROUND: Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections. METHODS: In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438. FINDINGS: Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI -12·46 to 25·13, p=0·524). INTERPRETATION: Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections. FUNDING: Netherlands Organisation for Health Research and Development.

A flowchart for building evidence-based care bundles in intensive care: based on a systematic review.

PURPOSE: The Institute for Healthcare Improvement is the founder of the care bundled approach and described the methods used on how to develop care bundles. However, other useful methods are published as well. In this systematic review, we identified what different methods were used to design care bundles in intensive care units. The results were used to build a comprehensive flowchart to guide through the care bundle design process. DATA SOURCES: Electronic databases were searched for eligible studies in PubMed, EMBASE and CINAHL from January 2001 to August 2014. STUDY SELECTION: There were no restrictions on the types of study design eligible for inclusion. Methodological quality was assessed by using the Downs & Black-checklist or Appraisal of Guidelines, REsearch and Evaluation II. DATA EXTRACTION: Data extraction was independently performed by two reviewers. RESULTS OF DATA SYNTHESIS: A total of 4665 records were screened and 18 studies were finally included. The complete process of designing bundles was reported in 33% (6/18). In 50% (9/18), one of the process steps was described. A narrative report was written about care bundles in general in 17% (3/18). We built a comprehensive flowchart to visualize and structure the process of designing care bundles. CONCLUSION: We identified useful methods for designing evidence-based care bundles. We built a comprehensive flowchart to provide an overview of the methods used to design care bundles so that others could choose their own applicable method. It guides through all necessary steps in the process of designing care bundles.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study.

BACKGROUND: Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy. METHODS: In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. DISCUSSION: This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. TRIAL REGISTRATION: Dutch trial registry: NTR6015 . Registered 9 August 2016.

Timely individual audit and feedback significantly improves transfusion bundle compliance-a comparative study.

OBJECTIVE: To investigate the difference in effect on transfusion bundle compliance between two Audit and Feedback (A&F) strategies to implement the transfusion bundle. DESIGN AND SETTING: This implementation study was conducted in an ICU of a university hospital from May to December 2014. The ICU consists of two nursing teams containing 63 and 62 nurses. PARTICIPANTS: All ICU nurses participated in this study. INTERVENTION: Monthly A&F on team level versus a combination of monthly A&F on team level plus timely individual feedback. MEASUREMENTS: The primary outcome was bundle compliance. Compliance was measured after every single transfusion. RESULTS: Monthly A&F on team level with timely individual A&F significantly improves bundle compliance during implementation compared to monthly A&F on team level alone. The overall effect of compliance during the study period was significantly higher with an OR of 4.05 (95% confidence interval, CI: 1.62 to 10.08), P < 0.001. This indicates that when using the combined A&F strategy nurses are more likely to be compliant to the bundle than when monthly A&F was used alone. CONCLUSIONS: Compared to monthly team A&F alone, providing timely individual A&F plus monthly A&F on team level significantly improves the success of implementing a transfusion bundle on the ICU during the implementation period. Providing timely individual A&F plus monthly A&F on team level might also be effective for the implementation of other bundles in healthcare. Future research could elaborate on longer duration of the intervention, the use of information and computer technology to lower costs of the intervention, and to enhance sustainability.

Emergency care within hospitals: can it be done more efficiently?

INTRODUCTION: Cardiac Arrest Teams (CATs) are frequently activated by nurses when patients experience 'false arrests' (FAs). In those cases activation of the Rapid Response Team (RRT) might be more efficient. The authors determined the level of urgency of FAs to find a scope for improvement in efficiency within emergency care. METHODS: CAT-activations for FAs in a university hospital from September 2009 to 2012 were retrospectively analysed and classified as urgent or less-urgent. RESULTS: In 26% (107/405) the CAT was activated for FAs. Calls were classified as urgent in 43% (46/107). Less urgent calls comprised 57% (61/107) of the FAs, difference 14% (95%CI: 1% to 26%). CONCLUSIONS: A significant part of the CAT-activations for FAs were less urgent and an RRT-activation might be more efficient. To minimise the CAT-activations for FAs, nurses need to recognise early patients who clinically deteriorate. Therefore, nurses should use the Modified Early Warning Score correctly.

What are effective strategies for the implementation of care bundles on ICUs: a systematic review.

BACKGROUND: Care bundles have proven to be effective in improving clinical outcomes. It is not known which strategies are the most effective to implement care bundles. A systematic review was conducted to determine the strategies used to implement care bundles in adult intensive care units and to assess the effects of these strategies when implementing bundles. METHODS: The databases MEDLINE/PubMed, Ovid/Embase, CINAHL and CENTRAL were searched for eligible studies until January 31, 2015. Studies with (non)randomised designs on central line, ventilator or sepsis bundles were included if implementation strategies and bundle compliance were reported. Methodological quality was assessed by using the Downs and Black checklist. Data extraction and quality assessments were independently performed by two reviewers. RESULTS: In total, 1533 records were screened and 47 studies were finally included. In 49 %, pre/post designs were used, 38 % prospective cohorts, and the remaining studies used retrospective designs (6 %), interrupted time series (4 %) and longitudinal designs (2 %). The methodological quality was classified as 'fair' in 77 %, and the remaining as 'good' (13 %) and 'poor' (11 %). The most frequently used strategies were education (86 %), reminders (71 %) and audit and feedback (63 %). Our results show that compliance is influenced by multiple factors, i.e. types and numbers of elements varied and different compliance measurements were reported. Furthermore, compliance was calculated within different time frames. Also, detailed information about compliance, such as numerators and denominators, was not reported. Therefore, recalculation of consistent monthly compliance levels was not possible. CONCLUSIONS: The three most frequently used strategies were education, reminders and audit and feedback. We conclude that the heterogeneity among the included studies was high due to the variety in study designs, number and types of elements and types of compliance measurements. Due to the heterogeneity of the data and the poor quality of the studies, conclusions about which strategy results in the highest levels of bundle compliance could not be determined. We strongly recommend that studies in quality improvement should be reported in a formalised way in order to be able to compare research findings. It is imperative that authors follow the standards for quality improvement reporting excellence (SQUIRE) guidelines whenever they report quality improvement studies.

Standardized measurement of the Modified Early Warning Score results in enhanced implementation of a Rapid Response System: a quasi-experimental study.

PURPOSE: To study the effect of protocolized measurement (three times daily) of the Modified Early Warning Score (MEWS) versus measurement on indication on the degree of implementation of the Rapid Response System (RRS). METHODS: A quasi-experimental study was conducted in a University Hospital in Amsterdam between September and November 2011. Patients who were admitted for at least one overnight stay were included. Wards were randomized to measure the MEWS three times daily ("protocolized") versus measuring the MEWS "when clinically indicated" in the control group. At the end of each month, for an entire seven-day week, all vital signs recorded for patients were registered. The outcomes were categorized into process measures including the degree of implementation and compliance to set monitoring standards and secondly, outcomes such as the degree of delay in physician notification and Rapid Response Team (RRT) activation in patients with raised MEWS (MEWS≥3). RESULTS: MEWS calculations from vital signs occurred in 70% (2513/3585) on the protocolized wards versus 2% (65/3013) in the control group. Compliance with the protocolized regime was presents in 68% (819/1205), compliance in the control group was present in 4% (47/1232) of the measurements. There were 90 calls to primary physicians on the protocolized and 9 calls on the control wards. Additionally on protocolized wards, there were twice as much RRT calls per admission. CONCLUSIONS: Vital signs and MEWS determination three times daily, results in better detection of physiological abnormalities and more reliable activations of the RRT.

Mumps outbreak among vaccinated university students associated with a large party, the Netherlands, 2010.

We investigated a mumps outbreak within a highly vaccinated university student population in the Netherlands by conducting a retrospective cohort study among members of university societies in Delft, Leiden and Utrecht. We used an online questionnaire asking for demographic information, potential behavioural risk factors for mumps and the occurrence of mumps. Vaccine status from the national vaccination register was used. Overall, 989 students participated (20% response rate). Registered vaccination status was available for 776 individuals, of whom 760 (98%) had been vaccinated at least once and 729 (94%) at least twice. The mumps attack rate (AR) was 13.2% (95%CI 11.1-15.5%). Attending a large student party, being unvaccinated and living with more than 15 housemates were independently associated with mumps ((RR 42 (95%CI 10.1-172.4); 3.1 (95%CI 1.7-5.6) and 1.8 (95%CI 1.1-3.1), respectively). The adjusted VE estimate for two doses of MMR was 68% (95%CI 41-82%). We did not identify additional risk factors for mumps among party attendees. The most likely cause of this outbreak was intense social mixing during the party and the dense communal living environment of the students. High coverage of MMR vaccination in childhood did not prevent an outbreak of mumps in this student population.